The nurse is assessing a client who came to the hospital with tonsilitis. Which finding should the nurse prioritize?
Temperature of 102.6 F (39.2)
Swollen lymph nodes
Difficulty swallowing
Tonsils are bright red
The Correct Answer is C
A. Fever is a common response to infection, including tonsillitis, and indicates the body’s immune system is active. Although important to monitor and treat with antipyretics if necessary, a fever is not immediately life-threatening and does not pose an urgent risk compared to airway compromise.
B. Lymphadenopathy reflects an immune response to infection and is often seen with tonsillitis. While it provides important diagnostic information, swollen lymph nodes do not present an immediate danger and are a lower-priority finding in acute assessment.
C. Dysphagia is the priority finding because it may indicate airway obstruction caused by swelling of the tonsils and surrounding tissues. In severe tonsillitis, enlarged tonsils can block the airway or make it difficult for the client to manage secretions. According to the ABC (Airway, Breathing, Circulation) principle, airway assessment and management always take precedence over other clinical findings. Difficulty swallowing can rapidly progress to respiratory distress, making it the most urgent concern for immediate intervention.
D. Erythema of the tonsils is a classic sign of infection and inflammation, confirming the diagnosis of tonsillitis. While this is important for clinical documentation and treatment planning, it does not indicate an immediate threat to the client’s airway or overall safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Placing a thermometer in the axilla (armpit) is used for axillary temperature measurement, not tympanic measurement. Axillary readings tend to be lower than core body temperature and are less accurate than tympanic or oral methods.
B. Oral temperature measurement requires a digital or glass oral thermometer, not a tympanic thermometer. Tympanic thermometers are designed specifically for the ear canal and use infrared technology to measure the temperature of the tympanic membrane.
C. Placing a thermometer on the forehead is used for temporal artery temperature measurement with a temporal artery thermometer. It is not the correct placement for a tympanic thermometer.
D. A tympanic thermometer measures body temperature by detecting infrared heat emitted from the tympanic membrane in the ear canal. Proper placement in the external auditory canal is essential for an accurate reading. For adults, the pinna should be gently pulled up and back to straighten the ear canal before inserting the thermometer. This method provides a rapid, accurate estimate of core body temperature.
Correct Answer is A
Explanation
A. White, cheesy, curd-like patches on the buccal mucosa are characteristic of oral candidiasis (thrush), a common fungal infection of the mouth caused by Candida albicans. These patches can often be wiped off, leaving a red, raw, or bleeding surface underneath. This is the classic presentation, making this the correct answer.
B. Small, painful round ulcers on the oral mucosa describe aphthous ulcers (canker sores), which are not fungal infections. They are usually idiopathic or associated with stress, trauma, or immune factors, so this option is incorrect.
C. Clear vesicles with a red base that evolve into pustules are more consistent with herpetic lesions caused by the herpes simplex virus. They are viral, not fungal, in origin, making this incorrect.
D. Chalky white, thick raised patches on the tongue may suggest leukoplakia, which is a precancerous lesion often linked to smoking or chronic irritation. Leukoplakia is not caused by fungal infection, so this option is incorrect.
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